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CMAJ Open. 2016 Dec 1;4(4):E729-E736. doi: 10.9778/cmajo.20160075. eCollection 2016 Oct-Dec.

Health care for children with diabetes mellitus from low-income families in Ontario and California: a population-based cohort study.

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Department of Paediatrics (Kaiser), University of California San Francisco, San Francisco, CA; Centre for Policy, Outcomes and Prevention (Sundaram, Sanders), Stanford University, Palo Alto, CA; Division of Paediatric Medicine, Department of Paediatrics (Cohen, Guttmann), Hospital for Sick Children and University of Toronto, Toronto, Ont.; Institute for Clinical Evaluative Sciences (Cohen, Shulman, Guan, Guttmann), Toronto, Ont.; Division of Endocrinology, Department of Paediatrics (Shulman), Hospital for Sick Children and the University of Toronto, Toronto, Ont.; Division of General Pediatrics (Sanders), Stanford University, Palo Alto, CA.



Children with diabetes mellitus in low-income families have poor outcomes, but little is known as to how this relates to healthcare system structure. Our objective was to gain insight into how best to structure health systems to serve these children by describing their health care use in 2 health system models: a Canadian model, with an organized diabetes care network that includes generalists, and an American model, with targeted support services for children from low-income families.


We performed a population-based retrospective cohort study involving children aged 1-17 years with type 1 diabetes mellitus. We used administrative data from between 2009 and 2012 from the California Children's Services program and Ontario. We used Ontario Drug Benefit Program enrolment to identify children from low-income families. Proportions of children receiving 2 or more routine diabetes visits per year were compared using χ2 tests, and diabetes-complication hospital admission rates were compared using direct standardization.


More California children from low-income families (n = 4922) received routine care for diabetes from pediatric endocrinologists (63.9% v. 26.9%, p < 0.001) and used insulin pumps (22.8% v. 16.4%, p < 0.001) than Ontario children (n = 2050).California children from low-income families were less likely than Ontario children to receive 2 visits for routine diabetes care per year (64.7% v. 75.7%, p < 0.001), and had slightly higher per-patient year hospital admission rates for diabetes complications (absolute differences 0.02, 95% confidence interval [CI] 0.02-0.02, for boys; 0.03, 95% CI 0.03-0.03, for girls).


Ontario children from low-income families received more routine diabetes care than did California children from low-income families. Both groups of children had clinically comparable rates of hospital admission for diabetes complications. Diabetes care networks that integrate generalists may play a role in improving access and outcomes for the growing population of children with diabetes.

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